Join us as experts explain the role of social, physical and other stress in migraine pain. You’ll learn how different kinds of stress can affect your migraines and how to manage the level of unhealthy stress in your life. Plus, you’ll find out why it's important to also look for underlying triggers during stressful situations if you want to prevent migraines in the future.

As always, our expert guests answer questions from the audience.

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Now here’s your host.

Rick Turner:

We all experience periods of stress in our lives. But if you have migraines, it can seem like stress turns into excruciating head pain. Is there a connection? What impact does stress actually have on people who suffer from migraines? Hello and welcome to our webcast, Is Stress Causing Your Migraines? I’m your host, Rick Turner. And during the next hour, we will learn the difference between good stress and bad stress and how it impacts a person with migraine. We will also learn to identify when you are under too much stress and explore some stress management techniques.

Joining us on the telephone from Chicago, Illinois is Dr. Merle Diamond. Dr. Diamond is associate director of the Diamond Headache Clinic in Chicago, and she is also attending physician at St. Joseph Hospital, and she joins us. Welcome to HealthTalk, Dr. Diamond.

Dr. Merle Diamond:

Thank you so much. It’s a pleasure to be here.

Rick:

It’s our pleasure to have you with us.

So, Dr. Diamond, we are talking about stress this program, stress and migraines. Can you define stress for us? Is there an easy definition?

Dr. Diamond:

Boy, that’s a good one because stress means so many different things to many different people. I think my best way of describing stress is it’s usually something either inside of you or outside of you that affects your level of awareness, and it can create excitability or overstimulation or worry, anxiety, pressure. And sometimes it can be good. I mean, stress can be a positive thing. But it changes your environment, and it changes you.

Rick:

Is stress the same thing as worry or anxiety?

Dr. Diamond:

No. Actually, they are different things. An anxiety is a true sort of psychological event where internally you can have fear. It might disrupt your thinking, feelings of negativeness. And actually it can cause you to have palpitations where your heart sort of flutters, shivering, even a feeling like you can’t get air sometimes. So it has physical components and emotional components, but it’s a bigger sort of psychological diagnosis. Stress is sort of a change, I call it almost a trigger.

Rick:

Okay. Well, that’s our next question because there has been a lot of controversy lately about whether stress is actually a migraine trigger or an aggravator. So is it a trigger, or does it just make one more susceptible to the real triggers for migraine?

Dr. Diamond:

Well, I think stress is a trigger for migraine because again it changes the excitability of your brain. And so people who suffer from migraines have more sensitive nervous systems, which get kind of turned on when there is a change. So it could be a change in your environment like the weather changing, or it could be a change in your excitability level, for example, with stress. So I look at it as a trigger.

Rick:

And does it make any difference if we define it as a trigger or an aggravator?

Dr. Diamond:

Well, I think some people like to say there is a big distinction between the two. I think the important thing for patients who suffer from migraine is to recognize, whether it’s a trigger or aggravator, that it’s a component of one of the things that can trip you into migraines. So if you have migraines and a change in your lifestyle, even if it’s a good one - so, for example, today I saw a lady who got a new job and it was great - she loves it, but her hours are different and her eating habits are different; new stress, new environment, so it’s a trigger, but she will adapt to it, and hopefully then her headaches will settle down.

Rick:

Let’s hope, yes. Now, in general do we know how stress impacts a person physically? What happens inside the body when someone is stressed?

Dr. Diamond:

Well, for some people it can cause a variety of different symptoms. For some people, it may cause insomnia, difficulty falling asleep or staying asleep. And if it progresses to anxiety, then it becomes more critical obviously. In some people, it may simply make you have a nervous stomach. People get nauseated, and they can’t eat, for some people, so, yes. It can have physical symptoms, and some of those physical symptoms include migraine.

Rick:

Yes.

Dr. Diamond:

So that’s the thing we are focusing on.

Rick:

And muscle tension, that sort of thing, does that actually change in people when they are stressed?

Dr. Diamond:

You know what? We haven’t ever been able to prove that muscle tension and tension-type headache is definitely connected, but clearly for some people they get tight. Their neck muscles get tight, and they do better when they can relax, do yoga, Pilates, stretch or have a massage.

Rick:

So tell us, Dr. Diamond, how does stress as best we can tell impact someone with migraine?

Dr. Diamond:

Well, I think the important thing for migraineurs to recognize is that there is a variety of different things that will lower their headache threshold. So skipping a meal, not sleeping well, having too much stimulation, too many things going on, stress are all things that can lower your headache threshold, and so kind of keeping on track with that, it doesn’t mean you need to have an avoidance behavior. You can’t avoid life.

Rick:

Right.

Dr. Diamond:

I mean, I do meet patients who kind of say, “Well, I just have to turn everything off and not have any input,” but that’s sort of hard to do in the real world. So what we try to do is have patients be able to recognize when that stress can turn on their migraines, and there are a lot of behavioral things people can do to actually stop a migraine before it starts when that’s going on.

Rick:

Good. And we are going to talk about some of those things a little bit later on in the program. Are there different types of stress in terms of chronic stress, is there emotional stress, acute stress? Can it be categorized like that?

Dr. Diamond:

Absolutely. And certainly I see patients who tell me, who will handle stress very well, and they don’t get their migraines until the stress is over. So they get letdown headaches.

Rick:

Yes.

Dr. Diamond:

So what happens to them is adrenaline kicks in. They function at a very high level, and then they sort of crash and burn after the difficult part is done. For other people, it happens during the stress. So we are all sort of made differently. It makes life interesting, but patients can recognize that. And again if they have migraine, they can recognize, “Well, characteristically it’s at the end of the cycle that I am going to get sick. What are the things that I am going to do to help prevent that from happening?”

Rick:

You just mentioned the impact of adrenaline or at least that come-down from the adrenaline rush. Is there any known connection between that? Is it like coming off an adrenaline high?

Dr. Diamond:

Well, for some people, yes. And if somebody asks me, “Well, where does that happen in the brain?” The answer is we really don’t know for sure yet. So I can’t point out the area in the brain that causes it to turn on the migraine, but we certainly know that patients with migraine have an easier turn-on of the migraine system which is in the brain stem, the base of your brain, when, for example, too much stress is occurring or hormones are changing or those kinds of things are going on.

Rick:

You mentioned earlier there is sometimes good stress. What would be an example of good stress?

Dr. Diamond:

Well, good stress is: “I am taking my son to college, and he is so excited about going, and I am excited about taking him, and I am packing, and I am getting ready, and we are driving on the road, and everything is great, and we get there, and it’s been just a flurry of activity, and he meets his friends, and he seems really comfortable.” So you have done a good job, and you get to walk away and say, “My kid is in a good place, and everything is settled.” And that’s a good stress in a way. It’s stressful to get them off to school. It’s stress, and it’s change, but it’s good. And that’s of one the things that can provoke patients. It’s very interesting.

Rick:

Yes. Even good stress.

Dr. Diamond:

Even good stress.

Rick:

Yeah. Well, it seems like there are everyday stresses like a busy day at work, and then there are major stresses, major life changes such the death of a loved one. Does the severity of stress seem to affect the likelihood of triggering a migraine?

Dr. Diamond:

I think in some patients definitely. So I see a lot of people during their grieving process if they have lost a loved one or somebody in their family has a catastrophic, terrible illness going on, they may have more trouble managing their migraines during that time. Part of that can be the stress, and part of it may be that they are helping [the other person] and not paying as much attention to their [own] body. Or they may not be sleeping as well because they are caretaking. So it’s often complicated, and when you talk to somebody who has migraines, it’s important to try to sort that out. How much of this is from your mood, and how much of this is because you are not sleeping and you are not eating regularly?

Rick:

Right. They’ve changed their routine.

Dr. Diamond:

Because some of those things you can help a little bit. And obviously with the grieving process, that’s a different issue.

Rick:

Yeah. And in terms of those non-major stressors, the everyday ones, can they sort of accumulate over time and have the same impact eventually as a major event?

Dr. Diamond:

Absolutely. So we see people who function at a very, very high level and have occasional migraines. And then for a number of reasons, their sleep pattern goes off, they get an illness of some sort, all of a sudden their headaches come fast and furious. And what used to be an easy level of activity becomes very difficult for them, and so their brain becomes more sensitive.

Rick:

So that has been a cumulative effect?

Dr. Diamond:

Absolutely. And what happens is - and a good way to think of it and the way I tell my patients to think of it - is that it’s almost like a fire. It’s sort of hard to get it burning. But once it’s burning and it’s got good, hot coals in there, it’s really easy to start the fire and get flames.

Rick:

Yeah.

Dr. Diamond:

And that’s sort of what happens with migraine if you are having a lot of migraine attacks. Those coals are very hot, and they get turned on really easily.

Rick:

On the same thought, Dr. Diamond, do people experience stress in different ways? That is to say, could a busy day at work for one person have virtually the same impact of the loss of a loved one on another person?

Dr. Diamond:

Absolutely. And so sometimes I will see people who have relatively minor traumatic events or something that might seem minor, really have a significant problem with their headaches getting worse. And all that means is that their nervous system is a little bit more sensitive, and it’s really not their fault. It’s just the way their nervous system interprets that stress level.

Rick:

Right. We also know that, of course, women experience migraine much more frequently than do men. Do men and women experience stress differently though?

Dr. Diamond:

I think probably they do, and I think behaviorally men often will hold things in, and probably not talk about what’s going on with them until they get to kind of a critical level. And I hate to generalize it because obviously everybody is different.

Rick:

Right.

Dr. Diamond:

But it is true. And women have more tension-type headaches, so women have three times more migraines, but they also have two times more tension-type headaches. So headache overall is more common in women.

Rick:

Right. And we know that women have migraine more than men, and we think, well, why not? In today’s world, many women have a lot more responsibilities. They are working. They are raising a family. They are running a household. Do you think there is a correlation between trying to be a supermom and stress and migraine?

Dr. Diamond:

Absolutely. And I would tell you that if you look at the severity of migraine as women age, we all think of migraine as getting better after menopause, but most of my patients are actually struggling more with their migraines between 35 and 45, so you are at the peak of your career.

Rick:

Right. Your kids are usually at home.

Dr. Diamond:

Right. And you are doing a million things, and what you used to be able to multitask at, you may find much more difficult. So there are a variety of things going on, including all of the hormonal changes, lack of sleep, and your body gets worn down.

Rick:

And for men, does it follow a pattern as well where there is a certain point in their life where it seems to peak because of the stress that their lives have?

Dr. Diamond:

Absolutely. And I don’t want to intimate that men, especially because I have a super husband, also have sort of that same peak in headaches around 35 to 45, and then again they decrease in number, but overall they suffer from far fewer migraines than women do.

Rick:

Dr. Diamond, we all have stress in our lives, but how much is too much, and at what point does it become harmful to our health, and how would we know that it’s stress that’s causing that?

Dr. Diamond:

Well, I think, what I have my patients do is I kind of talk to them about lifestyle, what they do for fun. For working moms or working dads, what’s your down time? How do you utilize it? When do you eat? What do you do for fun? And then talk about the number of hours they work. And it’s very funny. A lot of migraine patients tend to be very high achievers, so they kind of hedge, and they go, “Well, I work around 50 hours or so.” And I say, “Well, what’s the ‘or so’?” So you kind of have to get all the details and try to get people to open up about, what they do with their down time and if they even have any.

Rick:

Well, then you are asking people to sort of restructure their lives, aren’t you?

Dr. Diamond:

Perhaps. And that doesn’t mean changing your job or quitting your job or not doing your job appropriately, but certainly recognizing when you need a break, taking time for breathing and eating, putting some activity into your schedule if you can. For people who can, adding relaxation techniques if they can and they are willing to do it can be very helpful.

Rick:

And how do you know at what point you really need to make a change and you can’t just live with it and go on with it in the same routine that you follow?

Dr. Diamond:

Well, I think if you are having frequent migraines more than a few a month, and it’s disrupting your life, it’s time to go talk to somebody. And that doesn’t mean you necessarily have to take a medicine. Often behavioral changes can be extremely helpful and really lead people down a good path to feeling better.

Rick:

Uh-huh. We talked about how people experience stress in different ways and that stress can build up over time and accumulate. So in terms of nailing it down as a trigger, how tough is that? And does the old headache diary come into play here?

Dr. Diamond:

Yeah. I thank you so much for bringing that up. I have to tell you that headache diaries and headache calendars can be so helpful. Because one of the things you see in a headache diary not only is what the patient’s activity level is during the day, but, boy, you get a headache every Sunday night. Is that about going back to work? Is that about anxiety about going back to work? Or if you always get a headache Saturday morning, is that from caffeine withdrawal? Or is that because you are sleeping in and skipping breakfast? Or is it a letdown headache? And so you can learn a lot from a headache diary.

We also learn how patients take their medicines. So your headache started at 4 o’clock, but you didn’t take your medicine until 8. What was going on during those four hours? Were you trying to do other relaxation techniques, or did you just sort of ignore it and hope it would go away? So kind of learning all that stuff can be very helpful.

Rick:

And you mentioned that it could be something where you don’t know what the trigger actually was, if it was a caffeine letdown or whatever. So how do you separate out stress as a trigger from those other things?

Dr. Diamond:

I think if you keep a headache diary long enough, for a month, maybe two months, we can tell a lot from them. So we can see that it isn’t just the chocolate that you ate because a lot of people know that for them chocolate potentially could be a trigger or red wine or whatever. It seems to be coupled with the fact that you didn’t get to sleep on time, and you skipped a meal that day. And so what was going on? Well, I worked a 12-hour day because I was really busy, and so I kind of skipped dinner and got home and drank a glass of wine and went to bed, and kind of finding out about that. So it may not be just the stress. It could be all those things put together.

And I try not to get patients too focused on each individual thing. But certainly if you can recognize stress, have a good tool to cope with it that works for you, there are a lot of different tools, then it doesn’t have to control your life, and you can live pretty normally.

Rick:

And those little stressors that accumulate over time, is it more problematic identifying them?

Dr. Diamond:

Sometimes, yes. I think you really have to go back. Sometimes what I will do with patients is say because by the time I see them they might be having a ton of headaches, very frequent headaches, and sometimes I go back and I’ll say, “Let’s go back to two years ago before your headaches were so bad. Can you tell me what your headaches were like then and how much they impacted you, and what was your schedule like then?”

Rick:

Right.

Dr. Diamond:

So sometimes having a conversation, I know all of us doctors are a little bit too rushed when we see our patients these days, so I think it’s really important as a patient to make sure your doctor is aware of the progression of what’s happened with your headaches.

Rick:

Well, you have mentioned already there are several good ways to help manage stress, so let’s talk about some of those specifically. How do you recommend your patients manage stress generally?

Dr. Diamond:

Well, generally I always called them the ABCs of lifestyle. Make sure you have time for yourself. Even if you are a single parent and it seems like you are drowning, 10 minutes three times a day to read, breathe, walk if you can, something that’s just for you in terms of making sure you are kind of in check with your body. Obviously, that’s an extreme. So what we really try to do is teach people relaxation techniques, so just some relaxation phrases sometimes can be helpful for people, cognitive kind of using imagery to think about being someplace else, if you are in a stressful situation. Those are very easy things to do that can really help decrease your stress level. Even if you are in your work situation, if you can take three minutes, close the door, do some slow, relaxed breathing. Obviously if you have more time, we love yoga, relaxation exercises, massage. Unfortunately, insurance companies don’t pay for a lot of these activities, but they are excellent things.

And then we also try to teach our patients about biofeedback, which is an excellent technique that’s been around for a real long time that we use to help patients kind of get aware of what their neck muscles are doing, their body temperature, and use it to help manage pain.

Rick:

Okay. And we are going to talk a little bit more about biofeedback in just a second. But in terms of managing stress, Dr. Diamond, is there a difference between managing those major stressful events and the daily stresses, or do you take pretty much the same approach?

Dr. Diamond:

Well, I think it depends. If you have had a major stress, then sometimes it’s good to involve psychologists or psychiatrists to help if that’s warranted at the time. And sometimes therapy can be very, very helpful for major stressors. And I don’t want to minimize that because that can be extremely important for patients. But sometimes it doesn’t need to be a therapist.

Rick:

Right.

Dr. Diamond:

And we don’t need to progress to that point.

Rick:

So specifically about biofeedback, I am sure a lot of people have heard of it, but don’t really know what it is. What is it?

Dr. Diamond:

Well, biofeedback, I like to describe biofeedback as you are starting to pay attention to how your body behaves in terms of reflexes you don’t normally think about. So how do you breathe? What’s the tension in your neck? Are you frowning? Is your jaw clenched? These are things we don’t think about, but they are part of our structure, and they can affect headaches. And so what we do with biofeedback is we hook people up to machines. The machines read the muscle tension and your hand temperature, and then the machine gives you an idea of how tense you are by making a noise or sometimes some visual feedback. And there are different forms. And then the patient learns how to relax the muscles, and the machine will give you feedback as to how good a job you are doing.

And so what happens over time, and it usually takes patients somewhere between seven to 10 sessions to learn how to do this, is that you learn without using the machine what it feels like for your neck to be relaxed, to deep breathe, to relax your shoulder muscles, to relax your jaw. Because the machine has given you the cues and you can learn what those cues are, so you don’t have to buy a machine. You can learn it and use it.

Rick:

And then once you have that skill, you can actually change what your body is doing physically with your mind?

Dr. Diamond:

Absolutely. So who is good for biofeedback? Kids do great with it.

Rick:

Really?

Dr. Diamond:

People who are open to alternative treatments, I try to encourage my young women who are thinking about pregnancy to learn biofeedback, because obviously we want to minimize medication, and relaxation is a wonderful tool. And so biofeedback sometimes works as well as some of the preventative drugs we use.

Rick:

Wow.

Dr. Diamond:

And so I think the hard thing for patients with biofeedback is that, again, a lot of insurance companies don’t like to pay for it.

Rick:

Right. But you say once you learn this skill…

Dr. Diamond:

…you have it forever.

Rick:

It’s yours.

Dr. Diamond:

As long as you practice.

Rick:

Okay. Well, what about cognitive behavioral therapy or other stress management training programs, and coming to mind is the mindfulness-based stress reduction program developed by Jon Kabat-Zinn.

Dr. Diamond:

Right. I think those therapies can be very effective for patients. And I think one of the things that’s really nice about cognitive behavioral therapy is people think about therapy and they think that they may have to do it forever. This is something I have to do forever. And, of course, in our society, we want everything to be done now or yesterday. And so this is a tool that a lot of our patients can use to help become again aware of what’s happening around them at this time. And I am not an expert in this nor do I teach it, but it’s certainly a tool that many of my patients have used to help them through stressful situations, and it can be very effective when you find the right person and it’s a good match for you.

Rick:

And that brings us to medications. What sort of medications are available, Dr. Diamond, that actually help someone to manage their stress?

Dr. Diamond:

Well, everybody when they think about stress reducers thinks about, drugs like the benzodiazepines - Xanax (alprazolam) and Valium (diazepam) and that family of drugs. But a lot of medications that actually work to prevent migraine can help with anxiety reduction. So interestingly, and this is a drug that actually some people are using to treat post-traumatic stress disorder, Inderal, propranolol. It’s a very old drug. It’s been around for 50 years almost. And it’s a drug that works in migraine. And it can help with anxiety. And it’s not an addictive drug, and it can also help migraines. But one of things it does is it turns down that adrenaline switch. So it is interesting and has been looked at actually even in veterans who are coming back with PTSD.

Rick:

Uh-huh.

Dr. Diamond:

Other drugs like anti-depressants can sometimes be helpful. And I know some people are wary of them, but they can be used in very low doses because oftentimes we are not really treating anxiety and depression. We are treating the migraines, and so they can work as good preventative drugs in very low doses. And some of the muscle relaxants can sometimes work in chronic headaches as well. So there are a lot of options out there that can be helpful. One of the things that migraine patients worry about is that they will have to be on medicine forever.

Rick:

Yes.

Dr. Diamond:

And I think it’s important to recognize that migraine ebbs and flows. And so while you may need medicine for a period of time, you may not need it very long. And once the headaches are controlled, you may be able to not need that medication.

Rick:

And should patients be worried about developing a dependency on the medication?

Dr. Diamond:

No. No. And that’s something, of course, depending what you are put on, you need to talk about with your doctor. But most of the medications we use to prevent migraines are not addicting and don’t have long-term serious side effects. So I think it’s really important to talk to your doctor. Some of the anti-epileptic drugs - we call them neuronal stabilizers now - that’s a fancier name.

Rick:

Okay.

Dr. Diamond:

They can also work on overstimulation, and they help moods. So there are lots of different medications that are possible for patients to use. And what you need to talk to your doctor about is what are you comfortable with. So, for example, I saw a lady today who really didn’t want to take medication, and so we really worked on lifestyle, diet and biofeedback, and we found someone in her area who could help her with that. And so we are going to go down that path and see how good she can do with that, and hopefully that will be enough.

Rick:

So they are not necessarily viewed as a last resort as much as what the patient would be comfortable with?

Dr. Diamond:

Right. And sometimes we do both. So let’s say we see somebody who is having a lot of headaches and needs medication but also has a lot of stress and anxiety and isn’t really in touch with what their body is doing. That’s somebody who I would like to give both tools.

Rick:

I see. Sure.

Dr. Diamond:

That might be therapy, it might be cognitive behavioral therapy, it could be biofeedback, or it could be medication, and sometimes it’s a combination.

Rick:

How about self-medicating, Dr. Diamond, because I am sure some people resort to drugs and/or alcohol as a quick way to relieve stress and tension in their lives, what does that do?

Dr. Diamond:

I think that’s a really important thing that you brought up. So a lot of my patients will tell me, “If I have alcohol, it calms me down.”

Rick:

Right.

Dr. Diamond:

And I might not get a headache. The problem is that for some people it can be a trigger actually. And the other piece is the dependency issue. So if somebody comes in and says they have a glass of wine and they need it every six weeks, I don’t really get terribly excited about it. That’s okay. But if somebody is medicating themselves daily to keep themselves calm with a substance that’s addictive, then you have got to worry about it.

Rick:

Yeah. Well, we hear a lot about avoiding migraine triggers if possible, but are there actually ways to avoid stress altogether? You mentioned some people try to check out, remove themselves from all input in their lives, or is it more practical to learn how to manage stress?

Dr. Diamond:

Personally, and I know lots of people who struggle with migraines, certainly that’s all I do is see patients with headaches. So on my best day what I would recommend for people, and I hope it works, not everything fits every patient, is that they learn how to live in the world. And so that may involve learning biofeedback. It may involve cognitive behavioral therapy. It may involve medication. It may involve some lifestyle changes. But, obviously, I like for patients to be able to be present and not have to miss parts of their lives. And so I think you can manage that.

So for most people, and it’s not an answer for everybody, allowing them to learn about their bodies and kind of showing them different types of tools that can help them function better can really be life-altering. And so a lot of my patients will come back and say, “I thought that biofeedback stuff would be hokey, but it’s really helped me a lot.” And then again for patients who require it, cognitive behavioral therapy can be very effective.

Rick:

Great. If our listeners are looking for ways to help manage stress in their lives, is there a good resource for information for them, Dr. Diamond?

Dr. Diamond:

Well, I think absolutely. For headaches per se, go to the National Headache Foundation Web site. They are a patient-based advocacy group, and they will certainly give you tools and referral sources in your area. They also have a great information letter and have many different links that you can go to to kind of hook up and find other issues that may be more specific for you.

So let’s get to the questions. The first one comes from Fairfield, Ohio, “Can you help me understand why migraines come the day after the stressful situation rather than during it?”

Dr. Diamond:

Yeah. Well, that’s a great question, and a lot of my patients struggle with that. We believe that during the adrenaline rush or the overstimulation or the stressor that’s occurring, the adrenaline sort of protects your body, your brain, and it keeps you alert. And then it crashes, and it changes rapidly. So it’s sort of like skipping a meal or not sleeping well. It’s a change that affects your brain stem and gets the migraines turned on, and it’s the change in adrenaline, the stimulation your body is feeling that probably turns it on.

Rick:

Uh-huh. And speaking from my personal experience, I don’t get migraines, but I do get headaches from time to time, and I often notice that it’s the day after a stressful situation, so it’s not just migraine.

Dr. Diamond:

Exactly. Yes. It could be tension-type headaches.

Rick:

Okay. We have a question from Loveland, Colorado, “If you know that a stressful situation is impending, is there something you can do to try to divert the migraine that will follow? My neurologist recently talked about Valium to help with the stress, but this particular drug makes me nervous. Discussing the pros and cons of the situation would be great.”

Dr. Diamond:

Right. Well, I understand why people are nervous about Valium (diazepam) or Xanax or Ativan (lorazapam). They are all sort of in the same family. And if you have significant anxiety, that’s certainly a decision that you and your doctor need to make because they do have the potential to be addicting. But if you are only using them sporadically, not all the time, you don’t have to worry as much. Certainly if you want to try more natural things to do before you try Valium, I would recommend, for example, some patients will say, “Every time I have to go to a family event, I know that that’s a trigger for one of my headaches, and I get worried. Is everybody going to get along? Are we going to have fights?” Or just the travel to get there can do it for people.

Rick:

Sure.

Dr. Diamond:

So I tell people to make sure they are eating regularly, they try to keep their schedule as much normalcy as possible. So try not to change your sleep. Try not to change your eating. Try not to add foods that are triggers. And obviously if you know biofeedback, or exercise work effectively, so biofeedback, regular exercise can help. Try not to lose your strategies that help you with relaxation.

Rick:

And if you do take something like Valium in anticipation of a stressful situation, how well are you able to function with that? Does it make you sleepy?

Dr. Diamond:

Well, it’s a pretty sedating drug. Right. So you might go there but not really appreciate what’s going on around you.

Rick:

Yes.

Dr. Diamond:

So, again, I think using more natural coping techniques would be good. And for some people, that’s therapy. I once had a patient who every time she watched her son play football, and he was a very good football player, would get a migraine. And it would be during the game, and she couldn’t enjoy the game because she would be so nervous. And she didn’t want to have to take drugs to go watch her kid. So we actually did some talking about how she would get all overstimulated and anxious before his games, and so she worked with a therapist for a while. And she also learned biofeedback, and she was able to stop some of those headaches.

Rick:

Great. E-mail comes to us from Baton Rouge, Louisiana, “My 7-year-old daughter gets stressed out so easily, and I can tell that it causes migraines for her. How do I help her manage stress, a 7-year-old, and are there any medications that are safe for a 7-year-old?”

Dr. Diamond:

That’s a great question. So I am going to start with the first part first, and we’re going to talk about some nondrug therapies. So in children, what’s the right age for biofeedback and relaxation and all that stuff? And I would tell you for most children unless they are super bright and very precocious, I usually wait until they are 9 or 10 to teach them biofeedback because I want them to be able to retain it as a lifelong skill. Now, there are some kids who are younger who can do it, but I think closer to 9 or 10 they are going to retain it, and they are going to get what they are doing a little bit better.

Rick:

Right.

Dr. Diamond:

So for a younger child, I kind of act as the coach, and I teach the parents how to be a coach. So while they may not get the machine stuff, you can teach them how to do some relaxation breathing, slow, deep, methodical breathing. Because when a kid gets pain, they get very anxious and they breathe quickly, and they blow off a lot of carbon dioxide. They hyperventilate. So teaching them slow, deep breathing is good. Sometimes you can lay them down on the bed, put your hands under them and talk to them in a very soothing manner, which are some of the techniques we actually use with biofeedback. And you can kind of massage their backs, the back of their head and speak to them in a soothing manner. And then obviously removing that overstimulation, the Nintendo, the movie that’s screaming, too much music, too much stuff. And also in kids, be real careful about the stuff they are eating and the energy beverages that they drink.

Rick:

Energy beverages?

Dr. Diamond:

Absolutely.

Rick:

They are very popular these days.

Dr. Diamond:

They are very popular. They have a lot of caffeine and a lot of other additives, so always read the labels. You don’t need energy water. You just need water. Water is good without energy in it.

Rick:

Yes.

Dr. Diamond:

And then last, but not least, there are really unfortunately no drugs that are approved for use in children. Now, that doesn’t mean we tell our children who have migraines we are not going to treat you, but most of the medications we use in migraines are off-label. So I’d suggest if you know your daughter is having migraines, take her to her pediatrician. He or she may say, “I am not comfortable with it.” They may want her to see a neurologist or a specialist who does migraines, but there are certainly medications that are very safe to use in children. They are just off-label.

Rick:

Got it. From New York, New York, “I never had migraines before, and then a few months ago my husband passed away from cancer and, boom, I get migraines almost daily. Are they caused by this stressful event, do you think? And if so, will they ever go away?”

Dr. Diamond:

Well, I don’t know how old you are, and I am so sorry for your loss - a horrible thing. But the answer is that it is likely they will go away. However, I wouldn’t suggest that you simply wait for that to happen. Sometimes the trauma of the event can trigger this, and we certainly have seen this. And so there are lots of different approaches to that. There are certainly medications, but non-pharmacologic therapies may help as well, and so cognitive behavioral therapy sometimes in this situation can help immensely.

What’s your sleep pattern like? Are you eating? Are you taking good care of yourself? And go talk to your doctor about it, and make sure that you get an effective therapy. And again, it doesn’t necessarily have to be a medicine, but pay attention to those pieces because there are so many different things that they can do to help you.

Rick:

Is there good information on cognitive behavioral therapy on headaches.org, do you know?

Dr. Diamond:

They do talk about stress. And if not, I know that there will be links there for you to go to from their Web site because they link up with a lot of different excellent sites. The NHF Web site has been active for many, many years.

Rick:

E-mail comes to us from Sacramento, California, “Are there alternative medicines or supplements that I can take to reduce stress? I am very afraid to take the anti-anxiety drugs.”

Dr. Diamond:

There are. And certainly some of the herbal remedies can be helpful for patients. I am not an expert in those products. But I can tell you in terms of migraines, the most common ones that are effective are supplements like magnesium, coenzyme Q10, riboflavin, which is vitamin B2. The B vitamins are very, very good. And then sometimes for some people, some of the oils, peppermint oil can be helpful. So I think there are options available that are not traditional medications, and they can work. And I have seen them to be quite effective for people, and I would encourage you if that’s what you are comfortable with to talk to your doc about it. And they may not prescribe that stuff, but they can refer you to somebody who will.

Rick:

Yeah. It’s tough to get good solid information on that, right?

Dr. Diamond:

Yeah. The problem with herbal remedies isn’t that they are bad and that they don’t work. The problem is we don’t have a large volume of scientific information, and so because we don’t a lot of doctors pooh-pooh it as not being effective. And I don’t think that’s true. I think the problem is we don’t have a lot of science-based data, and so it’s harder to know how effective they are.

Rick:

Exactly. E-mail from San Francisco, California, “A few hours after a stressful situation, I begin to see floaters and zigzag patterns, but I don’t feel pain in my head. Is it possible I am having a migraine without a headache?”

Dr. Diamond:

Absolutely. And the old term for that was acephalgic migraine. Now it’s aura without migraine. They kind of change the names all the time. It is migraine, and it’s not dangerous. It’s obviously disturbing to have the visual distortion, and it tends to happen more as we get older. So patients who have migraines with aura when they were younger, oftentimes they won’t get the headache anymore. They will just have the aura.

Rick:

And is there anything in terms of the biofeedback or any of the other stress management techniques that are helpful in making that go away?

Dr. Diamond:

In that particular case, probably the best thing you can do - it’s sort of determined by how often you have it. So if you have it frequently I would certainly talk to your doctor because there are medications you can use to prevent it. I also think that using biofeedback and other techniques can certainly decrease the frequency of those attacks, and I would encourage people to use that.

Rick:

Okay. We have an e-mail from Seattle, Washington, “I know that emotional stress can trigger a migraine for me, but I also get migraines after a period of physical stress, like a long day of working on the house or a day skiing. Is it possible that being physically exhausted could also trigger a migraine? And if so, how can I avoid them when I know I am going to be physically active that day?”

Dr. Diamond:

Well, there are a couple of different things you can do. And those are called exertional migraines or benign exertional migraines. And so everything has a name. And people with regular migraines often get this type of headache as well, and it’s fairly predictable. So there are a couple of tricks. And you may have already tried these, but they are very important: really good hydration. Take breaks during the day. For patients with migraine and cluster headaches, we always talk about warm-up and cool-down, they’re very, very important. Don’t just go from heavy, heavy labor to crash and burn and laying in bed.

Rick:

Right.

Dr. Diamond:

So cool off slowly. There is a medicine called indomethacin or Indocin. It’s a very old nonsteroidal anti-inflammatory drug that’s been on the market for ages, and it actually is a very, very good drug for exertional headaches. And what we do is we have our patients if they know they are going to have a heavy labor day of whatever kind, they can pre-treat with this medication. We don’t like you to use it if you have an ulcer or kidney disease, but it’s a good drug and helps a lot of patients with exertional migraine.

Rick:

You mentioned hydration is important. How does that affect a migraine?

Dr. Diamond:

For many patients, inadequate hydration can be a trigger. So my classic example is I see a lot of kids who play sports. And, of course, they don’t want to drink during or before a game because they will have to go to the bathroom, and the coach will get mad. In fact, I had one of my parents call today to write a note because the coach wasn’t letting her son use the washroom, and I insist on him drinking because for him hydration is real critical in not getting his migraines. And the coach was mad at him. They get a little crazy sometimes. And so I wrote a note to the coach that he would miss more time with his migraine than he would be going to the washroom.

Rick:

Yeah, it’s a small price to pay.

Dr. Diamond:

Obviously, it’s common sense. But, yes, dehydration can affect it. And also be careful of the beverages you are drinking. So for some patients, those energy beverages will trigger headaches. Remember they have a lot of dyes in them. They have a lot of caffeine. And some of the flavored Gatorades, the dyes can affect people. So keep an eye on it. Keep that headache diary. It will help you see what’s a trigger.

Rick:

Yes. From Richmond, Virginia we get this e-mail, “What do you do when treatment of triptans fails, Topamax (topiramate) fails, anti-convulsants fail, anti-depressants fail and counseling fails?”

Dr. Diamond:

Well, I tell people, “Never give up.” And I always go back, and I think if you’re stuck and your doctor is stuck, keep your headache diary, go back and look at how the medications were used. Go back and see if you got to an adequate dose. Go back and see what time they were used for. Sometimes I will see patients, and they will say, “I tried it, it didn’t work. I tried this, it didn’t work.”

Rick:

Yes.

Dr. Diamond:

Sometimes they were never tried on [a large] enough [dose], or they had a side effect. And there are many options. People will say, “I have tried so many things. Nothing could possibly work.” Sometimes they haven’t tried things in combination. Sometimes they have been in rebound from a medication overuse when they tried things, so they couldn’t work. So I think it’s really always important if you are really, really stuck to have somebody fresh look at it. And never stop trying. Because I think most patients if we look at it, we can help 75 to 80 percent of patients have a better quality of life. That doesn’t mean a cure but a better quality of life. And so really fight for that treatment that might help you.

Rick:

That’s a lot. So it is reasonable to expect some level of improvement?

Dr. Diamond:

Yes. And I have to be honest. We don’t help everybody, nobody can. But the reality is it’s likely there is something out there that can help you. Don’t give up. Get a fresh look at it. You yourself take a fresh look at it and see somebody else. Try to get a fresh answer. Go down a different path.

Rick:

Yeah. Keep trying. Okay.

Dr. Diamond:

Keep trying.

Rick:

From Columbia, Tennessee we get this, “I have chronic migraines, but the pain I feel in my head when I am stressed is different than with my classic migraine. Could I have two different types of migraine, one caused by stress?”

Dr. Diamond:

Well, that’s a very interesting question, which if you got 10 headache specialists in a room, they would probably argue about it. What I would tell you is that the mechanism for the headaches, in other words what is happening in your brain, is the same, but the area of your brain that’s being impacted is distinct. So in English, what that means is that that brain stem thing we talked about earlier, that base of the brain getting turned on is happening with both types of headaches, but the expression or where it’s coming out in terms of pain is distinct. It’s in a different place.

Rick:

So it could feel different?

Dr. Diamond:

Absolutely. So a lot of patients with migraines, and I hear this all the time, say, “Seventy-five percent of my headaches are on the left side, my killer ones are on the right, and they are completely different. Is that a dangerous headache? Is that different migraine?”

Rick:

Yeah.

Dr. Diamond:

And it’s just the expression of that particular migraine attack.

Rick:

Fascinating. And we have this final question from Denver, Colorado, “How can I recognize the stress before I actually feel the hair is standing up on the back of my neck? That’s my biggest problem. After the hairs are standing up, then the warmth comes on, and then I feel the pain in my head.” So they want to sort of get ahead of that curve.

Dr. Diamond:

Right. So what I tell people to do because I am kind of one of those I like to say overachievers, overdoers, and sometimes I’m guilty just like anyone else is of not paying attention until it’s too late. So what I suggest to patients who are multi-tasking and busy in their lives and not sort of paying attention to their bodies is - and I know people kind of cringe at this, but it does work - put little stickies up. So if you have a work station you are at at your desk, put a pink or yellow or blue sticky up on your computer in the corner and look at it, train yourself to look at it every 45 minutes or so and check in with your body. Put one on your mirror at home in your bathroom.

Rick:

It’s just a reminder?

Dr. Diamond:

It’s a reminder to think about your body. Because a lot of us go through life kind of, “Well, I could do this. I am going to be okay.” And we don’t think about checking in with what our bodies are doing. And so like this particular person may crash and burn, and it’s almost too late before they know they are in trouble.

Rick:

Yeah. Okay. Well, we are going to have to leave it there because we are just about out of time. But before we go, I want to get some final thoughts from our guest. So, Dr. Diamond, what would you like to leave our listeners with regarding migraine and stress?

Dr. Diamond:

Well, I would like to encourage people to go to the National Headache Foundation Web site at www.headaches.org. It’s a wealth of information. For those of you who struggle with this issue like that patient who said they have tried so many things, there are new things coming down the pike. Please don’t give up. There are new medications all the time, and there is so much research going on. And we are understanding the brain and the link between stress and migraine better all the time, so hang in there.

Rick:

Great. Dr. Merle Diamond from Chicago, thanks very much for joining us. I have enjoyed it.